Curbside Consult: Spontaneous remission in bipolar illness

by | Jan 30, 2023 | Curbside Consults

Q. I saw a patient this week for an initial evaluation who has a historical diagnosis of bipolar disorder (likely type II). She was initially diagnosed while in graduate school at age 28, and experienced what was deemed to be a hypomanic episode, in the midst of her graduate studies and while completing, ironically enough, a mindfulness-based stress reduction course. She was reportedly put on lamotrigine, titrated up to an unknown dose (she thinks it was at least 100mg) and remained on that until her mood stabilized. She eventually discontinued the lamotrigine and reportedly has remained well for the last nine years, with no reported recurrences of hypomania. There is much more to the story (emotional abuse and medical trauma, long history of unidentified chronic illness including autoimmune conditions of gluten ataxia and eosinophilic esophagitis), but what puzzled me most and what inspired me to reach out to you was the fact that she reportedly stayed “stable” for nine years until recently. Due to an acute illness with nephrolithiasis, she lapsed into another depressive episode with ongoing suicidal ideation for the last six weeks. She came to me seeking to restart her lamotrigine. I informed her that there is not a lot of evidence to support its use in acute illness and that it is mainly a preventative medicine. I discussed the option of lithium with her, both for the benefits of treatment of depressive symptoms but also it’s anti-suicide effects. She would like to discuss with her mother, who also has bipolar disorder and is stable on both lamotrigine and lithium and I am waiting to hear back from her.

My main question to you is this: Is it theoretically possible and/or plausible that this woman could experience a period of stability lasting nine years with no pharmacologic treatment for her bipolar disorder? She was potentially interested in “short term” treatment for this acute episode, which apparently has been triggered by negative life events such as this acute illness, death of her family cat and also being laid off from her job. Would “short-term” lithium therapy be appropriate?

A. Yes, a person can go a decade or so, or even decades, without any medication treatment and be in full remission with bipolar illness. I had a friend who had his one and only episode of depression at age 35, treated for a year and resolved, and then went untreated without an episode for over three decades, before a severe depression in his late 60s that ended in suicide.

That’s the nature of manic-depressive illness, which is defined as recurrent mood episodes of any kind (unipolar or bipolar). It is recurrent, so there will be more than one episode, but years and decades can pass between episdoes. Of one thing you can be certain, a first episode will be followed by a second at some point. As my friend’s example shows, that second episode could be the last one because it is fatal.

This does not mean that patients should be treated in all cases for years or decades when they would not have had an episode spontaneously, but the problem is that only God knows whether or not a remission period will last one year or ten years. Since clinicians should realize that they are not God, we have to be humble, and treat. Of course the patient can refuse and wait, but our recommendation should be to treat. Perhaps at low dose, perhaps lightly, but treat. If light and at low dose, the most effective preventive treatment is lithium.